Health inspection·November 25, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. Based on resident interview, medical record review, staff interview, and facility policy review, the facility failed to ensure routine care plan conferences were conducted. This affected two residents (#150 and #73) of five residents reviewed for care plan conferences. The census was 108.Findings include:1.Record review of Resident #150 revealed an admission date of 09/04/19 with diagnosis that include Parkinson's disease, schizophrenia, bipolar disorder, hypothyroidism, dementia, and muscle weakness. Review of Resident #150's Brief Interview for Mental Status (BIMS) score completed on 08/12/25 revealed a score of 0 due to resident being unable to complete assessment questions, indicating severely impaired cognition. Review of Resident #150 care plan history from 07/01/23 through 11/12/25 revealed the resident's care plan was updated on 5/23/25, 08/19/25, 09/19/25, and 10/14/25.Interview on 11/13/24 at 11:54 A.M. with Resident #150 Power of Attorney (POA) revealed she attended a care conference in March 2025 with a previous Director of Social Services but had not had one since March 2025. Resident #150's POA reported she had left messages with the new Director of Social Services but had not heard back.2. Record review of Resident #73 revealed an admission date of 07/10/25 with diagnosis that include: dementia, muscle weakness, essential hypertension, impulse disorder and insufficient sleep syndrome. Review of Resident #73's BIMS score completed on 10/15/25 revealed a score of 00 due to resident being unable to complete assessment questions, indicating severely impaired cognition. Resident #73's spouse was listed as his emergency contact and responsible party.Review of Resident #73's record revealed an admission care conference was held on 07/22/25 with Resident #73's spouse and other facility staff. Resident #73's care plan was updated on 10/22/25 but the record did not include any additional care conferences had been held.Interview on 11/13/25 at 10:07 A.M. with Director of Social Services (DSS) #421 revealed care plan meetings are held upon admission, quarterly, and whenever there is a significant change in condition. Care conferences are held with the resident, their family members, guardians, nurses, and certified nursing assistants. DSS #421 confirmed a care conference had not been held for Resident #150 and his daughter was not in attendance. Director of Social Services #421 reported she was behind on scheduling and conducting resident care conferences. DDS #421 was not aware of any missed calls from Resident #150 daughter. DDS #421 revealed Resident #73's spouse was not involved in his care conferences and that she was just the emergency contact. Review of the facility's Comprehensive Care Planning Policy dated 03/20/25 revealed the comprehensive care plan will be prepared by an interdisciplinary team that includes but is not limited to: To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representatives is determined not to be practicable for the development of the resident's care plan.This deficiency represents non-compliance investigated under Complaint Number 2656169. Page 1 of 14 365432 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to inform a resident's physician of ongoing medication refusals and failed to ensure resident representative were notified of changes. This affected three residents (#62, #103 and #106) of six residents reviewed for notification of change in condition. The facility census was 108.Findings include: 1.Review of Resident #62's medical records revealed an admission date of 11/07/17. Diagnoses included bipolar, psychosis and schizoaffective disorders Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #62 had intact cognition. Review of current physician orders for November 2025 revealed Resident #62 was ordered Risperdal (an antipsychotic) 25 milligrams/2 milliliter injection on Wednesday every two weeks. Review of Resident #62's Medication Administration Record (MAR) from October 2025 and November 2025 revealed Resident #62 had refused biweekly Risperdal injections on 10/01/25, 10/15/25, 10/29/25, and 11/12/25. Review of Resident #62's progress notes from October and November 2025 revealed no documentation related to Resident #62's medication refusals or the physician being notified of refusals. Interview on 11/18/25 at 12:20 P.M. with Licensed Practical Nurse (LPN) #402 revealed Resident #62 had been ordered Risperdal injections every two weeks. LPN #402 stated the medications were documented as being refused, however no one had told the family or the physician. Observation at time of interview revealed four boxes of single injection Risperdal with Resident #62's name on them. Interview on 11/18/25 at 1:45 P.M. with Director of Nursing (DON) confirmed if a medication had been refused the physician and resident representative should be notified. Review of Resident #62's medical records with DON at time of interview confirmed no documentation related to medication refusals had been recorded. 2. Review of Resident #103's medical records revealed an admission date of 01/11/23. Diagnoses included cognitive impairments, dementia and anxiety. Review of the MDS assessment dated [DATE] revealed Resident #103 had impaired cognition. Review of Resident #103's physician orders revealed on 10/07/25 Resident #103 was ordered Benadryl (an over the counter medication used to treat allergy symptoms and skin rash) every four hours as needed and hydrocortisone cream (a topical corticosteroid used to relieve redness, itching, and swelling from skin irritation). On 10/21/25 and 10/30/25, Resident #103 was ordered Permethin (synthetic insecticide used to treat parasitic infections including scabies). Review of Resident #103's progress notes revealed a note dated 10/07/25 which referenced Resident #103 had redness to right and left extremities. The hospice nurse was notified and orders for Benadryl and hydrocortisone cream were received. The progress note did not include resident representative notification of the new orders. Review of a note dated 10/22/25 authored by LPN #420 revealed there 365432 Page 2 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was a new treatment for a skin rash. The note did not include that the resident's representative had been notified of the new orders. There was no progress notes referencing the 10/30/25 order for Permethin. Interview on 11/18/25 at 1:45 P.M. with the DON confirmed there was no evidence Resident #103's representative had been notified of the new orders. The DON reported medication changes should be discussed with the resident's representative. 3. Review of Resident #106's medical records revealed an admission date of 10/04/24. Diagnoses included dementia, Huntington's disease and restlessness. Review of the MDS assessment dated [DATE] revealed Resident #106 had no cognition score due to being rarely/never understood. Review of progress note dated 10/13/25 authored by LPN #360 revealed a new order for prednisone (steroid) for seven days for inflammation. Progress note did not include resident representative notification. Interview on 11/18/25 at 1:45 P.M. with the DON confirmed there was no evidence Resident #106's representative had been notified of the new orders. The DON reported medication changes should be discussed with the resident's representative. Review of facility policy titled Resident Change in Condition Policy reviewed 06/02/25 revealed physician/family/responsible party will be notified when there has been a need to alter a resident's medical treatment. This deficiency represents non-compliance investigated under Complaint Number 2656169. 365432 Page 3 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review The facility failed to ensure medication consumption was monitored to ensure medications were safely swallowed. This affected one resident (#28) of four residents observed and reviewed for medication administration. The facility census was 108. Findings include: Review of Resident #28's medical records revealed an admission date of 06/05/15. Diagnoses included stroke with left sided weakness, muscle weakness dysphagia (difficulty swallowing) and dementia.Review of Resident #28's physician's orders revealed an order dated 05/12/23 that medications may be crushed unless contraindicated. Resident #28 additionally had an order dated 06/16/25 for acetaminophen (an over-the-counter mild pain reliever) 650 milligrams (mg) every six hours as needed for pain. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had no recorded cognition score due to the resident was rarely/never understood. Observation of wound care on 11/10/25 at 11:47 A.M. with Licensed Practical Nurse (LPN) #402, LPN/Assistant Director of Nursing (LPN/ADON) #341 and Regional Registered Nurse (RRN) #452 for Resident #28 revealed Resident #28 was expressing non-verbal complaints of pain that including withdrawing his leg and foot when his right leg was touched. At the time of observation, RRN #452 had informed LPN #402 to administer pain medication as ordered. LPN #402 had exited Resident #28's room and had returned with a cup of crushed medications mixed with applesauce that LPN #402 had indicated was the resident's as-needed acetaminophen. LPN #402 administered the crushed medication to Resident #28 and exited his room. RRN #452 had remained in the room and asked if Resident #28 had swallowed his crushed medication and RRN #452 confirmed Resident #28 had not swallowed them. RRN #452 proceeded to manually massage Resident #28's throat in order to stimulate his swallowing. RRN #452 stated LPN #402 should have stayed present to ensure medications had been swallowed prior to exiting the room. This deficiency represents non-compliance investigated under Complaint Number 2657376. Residents Affected - Few 365432 Page 4 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, review of hospital medical records, review of a local in-progress police report, policy review and interview, the facility failed to adequately and accurately identify and record a decline in a wound for Resident #150. This affected one resident (#150) of three residents reviewed for wounds and skin impairments. The facility census was 108. Actual Harm occurred on 10/21/25 when Resident #150 was admitted to the hospital with altered mental status, a urinary tract infection, dehydration, and malnutrition and assessed to have an unstageable pressure ulcer (a full-thickness wound where the depth of the damage cannot be determined because the wound bed is obscured by dead tissue) to the coccyx (tailbone area) that measured seven centimeters (cm) in length by eight cm in width. Resident #150's coccyx's wound was noted to have a foul odor and a moderate amount of serosanguineous drainage with 60% of the wound bed noted to have brown and black eschar (dead tissue) and the remainder was a mixture of yellow slough and red and moist wound bed. Resident #150's family declined surgical debridement and Resident #150 was admitted to palliative care. Resident #150 was hospitalized until 10/24/25, at which time he transferred to a local residential hospice facility where he later passed away on 11/02/25. Findings include:Review of Resident #150's closed medical records revealed an admission date 09/04/19 with diagnoses including Parkinsons, dementia, muscle weakness and need for personal care assistance. Resident #150 was transferred to a local hospital on [DATE] and did not return to the facility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #150 had no cognition score due to being rarely/never understood. Resident #150 was noted to be dependent on staff for toileting, bathing, and bed mobility tasks. Review of a Braden Scale (tool used to predict a patient's risk for developing pressure ulcers) dated 10/10/25 revealed Resident #150 scored a 15 indicating he was at mild risk for developing pressure ulcers. Review of the care plan revised on 10/14/25 revealed Resident #150 was at risk for activities of daily living (ADL) decline. The care plan noted Resident #150 was dependent on staff for toileting, bathing, and bed mobility and was incontinent of bowel and bladder. Resident #150 was additionally noted to be at risk for pressure ulcer development. Listed interventions included to provide incontinence care as needed, utilize barrier cream after incontinence episodes, utilize a pressure reducing mattress, complete weekly skin evaluations, keep skin as dry and clean as possible, avoid friction to the skin, and report any signs of skin breakdown. Review of a wound progress note authored by Wound Nurse Practitioner (WNP) #450 dated 10/16/25 revealed Resident #150 was seen for moisture-associated skin dermatitis (MASD, inflammation of the skin caused by prolonged exposure to moisture) to the sacrum and bilateral buttocks. The MASD was described as partial thickness and measured six centimeters (cm) in length by six cm in width with 0.2 cm depth. The wound bed was recorded to be 70% pink and 30% epithelial with moderate serous (clear) drainage. The wound status was determined to be unchanged but referenced the resident was having large, soft stools, and noted excoriations to the right buttock. The treatment orders included to cleanse the area with normal saline, apply calcium alginate (absorbent wound dressing used for moderate to heavy drainage), and cover with a clean dry dressing daily and as needed, and to continue the current treatment for one week. There were no additional or new orders/interventions to address the large, soft stools referenced in the progress note or to ensure the resident's skin was not subjected to prolonged moisture related to the resident's incontinence. Review of a head-to-toe assessment dated [DATE] authored by Licensed Practical Nurse (LPN) #376 revealed Resident #150 had moisture-associated skin damage (MASD) to his buttocks. Review of Resident #150's progress notes revealed a note dated 10/21/25 at 11:33 A.M. authored by Licensed Practical Nurse/Assistant Director of Nursing (LPN/ADON) Residents Affected - Few 365432 Page 5 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0686 Level of Harm - Actual harm Residents Affected - Few #341 reflected Resident #150's Power of Attorney (POA) was called regarding a change in condition. The note further referenced an unnamed Nurse Practitioner (NP) provided an order to send Resident #150 to a local emergency room for evaluation. A follow up note timed 2:16 P.M. authored by LPN #376 revealed Resident #150 had been noted to have a continual decline in cognition, was unable to answer questions or communicate needs. Resident #150 was not swallowing food, medications, and pocketing was noted. The note referenced a call was placed to an unnamed NP who ordered the resident be sent out to a local emergency room for evaluation. Review of hospital records dated 10/21/25 revealed Resident #150 was transferred to a local emergency department for evaluation. The record stated the facility noted Resident #150 had mental status changes since the night of 10/19/25 (however, the resident's medical record from the facility did not include documentation of these mental status changes) and the resident had been less responsive than normal. Emergency Medical Services (EMS) reported the resident was usually alert and oriented to person, place and time but was now non-verbal. Resident #150 was noted to have critically elevated sodium levels and was admitted into the intensive care unit (ICU) with hypernatremia, an acute urinary tract infection, and altered mental status. Resident #150 was noted to have a decubitus sacral wound that was noted to have been present on admission. Review of the hospital initial wound assessment dated [DATE] revealed Resident #150 was seen for an initial assessment. The note indicated an old dressing was removed. Resident #150's wound was cleansed and gently mechanically debrided with saline and gauze. The note stated the coccyx wound was an unstageable pressure ulcer measuring seven cm in length by eight cm in width, with no depth recorded. The wound was noted to have a found odor when the dressing was removed, with a moderate amount of serosanguineous drainage with 60% of the wound with brown to black eschar (dead, blackened tissue that forms over a wound), with the remainder a mixture of yellow slough (another type of dead tissue that is often stringy and moist and can delay healing and increase infection risk) and red moist wound bed. The peri-wound (skin surrounding the wound) was macerated (where the surrounding skin has softened and broken down due to prolonged exposure to moisture, such as from wound drainage, sweat, and/or incontinence). The note referenced a surgical consult for debridement was recommended. Review of a hospital progress note dated 10/23/25 revealed Resident #150's family members were present at bedside after flying in from out of state. Resident #150 was noted to have an overall deconditioned state, and palliative care was consulted for a goals of care discussion with the resident's family. The family expressed frustration at Resident #150's prior facility, noting discrepancies between information provided and the patient's current, critical condition. After discussion with hospital providers the family members opted to proceed with hospice care. The note referenced a hospice consult was placed and communicated to the hospice liaison and case manager. A follow up note dated 10/23/25 revealed Resident #150's code status had been changed to Do Not Resuscitate Comfort Care. The family members present indicated they did not wish for Resident #150 to receive cardiopulmonary resuscitation (CPR) or intubation, but rather complete comfort care while still treating his wound and urinary tract infection. Review of a local police report dated 10/26/25 revealed an allegation of patient abuse and neglect had occurred at the facility. The report indicated an investigation was pending and listed the facility as an involved party. Review of the supplemental report narrative revealed an officer met with a local attorney at the local police department on 10/26/25 to discuss possible abuse of a patient at the facility. The attorney indicated the patient involved was Resident #150. The narrative included information that upon arrival to the local hospital on [DATE], Resident #150 was noted to be extremely malnourished and had a severely necrotic wound on his coccyx that was going to need surgery. An additional supplement to the report noted that on 11/03/25, an officer spoke with a 365432 Page 6 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0686 Level of Harm - Actual harm Residents Affected - Few representative from the local regional forensic science lab after obtaining information that Resident #150 passed away on 11/02/25. The report noted that an autopsy was pending on Resident #150, and that detective follow up would be needed. The report indicated the investigation was on-going. Telephone interview on 11/10/25 at 3:30 P.M. with Resident #150's POA revealed she had filed a complaint with the local ombudsman and the local police department related to neglect of Resident #150 that included her not being made aware of Resident #150's wound and the severity of the wound upon the resident's arrival to the hospital on [DATE]. The POA reported on 10/21/25 at 10:32 A.M., she had received a voicemail message from LPN/ADON #341 that Resident #150 had a change in condition. The POA stated she had immediately returned the call to the facility and had been informed Resident #150 was out of sorts and was going to be sent to the hospital for evaluation and treatment. The POA stated she had spoken with the physician at the hospital and had been told Resident #150 had a severe wound to his buttocks that would require surgical intervention, but that Resident #150's wound was severely infected, and the resident may not survive the surgery. The POA stated due to Resident #150's condition upon arrival to the hospital, the physician had stated Resident #150 may not survive for more than a week, and after discussion, she and the family had made the decision to place Resident #150 into hospice for comfort care. A follow up interview with Resident #150's POA on 11/12/25 at 9:32 A.M. revealed Resident #150 had passed away on 11/02/25 and an autopsy had been performed with the results pending. Telephone interview on 11/12/25 at 2:29 P.M. with WNP #450 revealed she had evaluated and treated Resident #150 on 10/16/25 for Moisture Associated Dermatitis to his buttocks and had given orders to cleanse the area with normal saline, apply calcium alginate and cover with a clean dry dressing daily and as needed. WNP #450 stated she had not been made aware of any concerns related to a decline in Resident #150's wound. Interview on 11/12/25 at 2:55 P.M. with LPN/ADON #341 revealed she was the facility's wound nurse; however, she had not had any official training or certification. LPN/ADON #341 stated she had performed wound rounds with WNP #450 every Thursday and had seen Resident #150 on 10/16/25 at which time he was noted to have had MASD to his buttocks and stated his skin alterations were not considered a pressure ulcer. LPN/ADON #341 stated WNP #450 had ordered for the calcium alginate and a foam dressing to be applied to the wound daily and as needed. LPN/ADON #341 stated Resident #150 had been sent to the hospital on [DATE] due to a change in condition that included difficulty swallowing. LPN/ADON #341 stated she had attempted to contact Resident #150's POA, however she had only left a voicemail message. LPN/ADON #341 stated she had then called to arrange for transport to the hospital and had not sent Resident #150 via emergency services. LPN/ADON #341 stated she had obtained a copy of Resident #150's hospital paperwork a few days later and noted Resident #150 had been admitted with a pressure ulcer that may have required surgery. LPN/ADON #341 denied being made aware of any concerns related to Resident #150 having a pressure ulcer prior to his hospital admission. Interview on 11/13/25 at 8:06 A.M. with LPN #376 revealed she cared for Resident #150 on 10/21/25. She recalled Resident #150 was not responding normally and he had not been swallowing or drinking. LPN #376 stated she had informed LPN/ADON #341 and contacted the facility's nurse practitioner who had advised to send Resident #150 to the hospital for evaluation. LPN #376 stated she had assisted with Resident #150's incontinence care prior to his transport to the hospital and she was shocked when she had seen Resident #150's wound. LPN #376 stated she had seen Resident #150's wound approximately a week prior but on the morning of 10/21/25, the resident's coccyx wound was much larger, deeper, had black areas, and a foul odor. LPN #376 stated she had informed LPN/ADON #341 about the wound via text message the morning of 10/21/25. LPN #376 provided a copy of the text message for review. Review of text messages on 10/21/25 at 9:16 A.M. sent from LPN #376 to LPN/ADON #341 stated 365432 Page 7 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0686 Level of Harm - Actual harm Residents Affected - Few Are we charting the unstageable wound on Resident #150's bottom. And moving forward I'm charting everything I see to protect by license as well as my residents. LPN #376 received a response from LPN/ADON #341 which stated Its documented as MASD. WNP is trying everything to not change it to pressure. LPN #376's response to LPN/ADON #341 was You and I know what his wound really is. A follow-up interview on 11/13/25 at 9:56 A.M. with LPN #376 revealed she had been told by LPN/ADON #341 to not document Resident #150's wound as a pressure ulcer and to continue to document the wound as MASD. LPN #376 confirmed she had documented Resident #150's head-to-toe assessment on 10/21/25 and had documented Resident #150's wound as MASD. She stated she should not have documented the wound that way as she knew the area to Resident #150's coccyx was an open pressure ulcer. Interview on 11/17/25 at 8:25 A.M. with Certified Nursing Assistant (CNA) #366 revealed she had cared for Resident #150 on 10/20/25 and 10/21/25. CNA #366 stated she had observed Resident #150's wound on 10/20/25 and the wound to his buttock was a large, open wound that was necrotic and had a foul odor. CNA #366 reported on the morning of 10/21/25, she had cared for Resident #150 and he seemed off. CNA #366 stated she had informed LPN #376 and had then assisted with Resident #150's incontinence care and had also observed Resident #150's wound. Interview on 11/17/25 at 9:16 A.M. with the Director of Nursing (DON) and Regional Registered Nurse #451 revealed they had interviewed LPN #376 on 11/13/25 and had obtained a statement. Review of LPN #376's statement dated 11/13/25 revealed on 10/21/25, Resident #150 had a wound and was not acting as himself. The statement included on 10/17/25, the wound was stable and on 10/20/25, LPN #376 had noted a decline in the area, and she had last seen Resident #150's wound approximately a week prior. The statement further included when LPN #376 was asked why she had documented Resident #150's wound as MASD on his head-to-toe assessment, LPN #376 responded I probably shouldn't have, but that was what everyone else was calling it. RRN #451 stated she had attempted to obtain more specific information regarding a description of Resident #150's wound from LPN #376, however LPN #376 had been difficult during the interview and had not provided any additional information. Interview on 11/18/25 at 1:45 P.M. with DON and RRN #451 revealed they had obtained a questionnaire from LPN #376 regarding Resident #150's condition prior to hospitalization. Review of LPN #376's questionnaire with the DON and RRN #451 revealed Resident #150's sacral wound had significantly declined and LPN/ADON #341 had been informed. Review of the policy Skin and Wound Care Best Practices last reviewed 09/17/25, revealed the purpose of the policy was to provide evidence based preventative skin care and wound treatment to prevent unavoidable skin complications. The policy referenced the licensed nurse will complete a Weekly Skin Check. The interdisciplinary team will review residents with pressure injuries/wounds during the resident review meeting. Review of the policy Change in condition last reviewed on 06/02/25 revealed the physician and responsible party will be notified when there has been a significant change in the resident's physical condition. This deficiency represents non-compliance investigated under Complaint Numbers 2657376 and 2656169. 365432 Page 8 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility fall investigation, emergency medical services (EMS) run report, and facility policy review, the facility failed to ensure an accurate and thorough fall investigation was completed. This affected one resident (#150) of three residents reviewed for falls. The facility census was 108.Findings include: Review of Resident #150's closed medical records revealed an admission date 09/04/19 with diagnoses including Parkinson's, dementia, muscle weakness and need for personal care assistance. Resident #150 was transferred to a local hospital on [DATE] and did not return to the facility.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #150 had no cognition score due to being rarely/never understood. Resident #150 was noted to be dependent on staff for toileting, bathing, and bed mobility tasks. Review of the care plan revised on 08/12/25 revealed Resident #150 was at risk for activities of daily living (ADL) decline. Interventions included two staff assistance with personal hygiene, bed mobility, transfers and toileting. Resident #150 was at risk for falls and interventions included keeping the bed in the lowest position with brakes locked.Review of a progress note dated 10/02/25 timed 4:06 A.M. authored by Licensed Practical Nurse (LPN) #414 revealed she had been alerted Resident #150 had fall. Upon assessment Resident #150 was observed to have had a small one inch laceration to his forehead and another small laceration on his right knee. Resident #150's heart rate was 130 beats per minute (elevated, normal range is 60-100) and oxygen saturation was 65% (low, normal range is 92-100%). On call physician was notified and Resident #150 was sent to the hospital.Review of the facility fall investigation dated 10/02/25 revealed a statement authored by Certified Nursing Assistant (CNA) #336 that stated Resident #150 was last observed at approximately 2:20 A.M. and at approximately 3:00 A.M,. Resident #150 was observed on the floor by the right side of his bed. CNA #336 had immediately notified the nurse. Review of Post Fall Huddle authored by LPN #414 revealed date of fall at 10/02/25 at 3:00 A.M. with Resident #150 last being toileted at 2:20 A.M. Review of an EMS report dated 10/01/25 revealed a call for EMS services was received at 11:44 P.M. The report noted EMS personnel arrived on scene at 11:52 P.M. The EMS narrative included a call was received for a patient who had fallen and upon EMS arrival at the facility, an unnamed nurse had met EMS personnel at the elevator and stated Resident #150 was found next to his bed two hours prior to EMS arrival. The report noted it was assumed Resident #150 had fallen. The unnamed nurse stated they had helped Resident #150 back into bed and had contacted EMS for abnormal vital signs and reported Resident #150 had a small laceration to his forehead which the nurse stated was from a prior fall. The report noted the resident was transported to a local hospital and EMS departed the scene on 10/02/25 at 12:03 A.M. Review of hospital paperwork dated 10/02/25 timed 4:30 A.M. revealed EMS had arrived to facility for a chief complaint of a fall and abnormal vital signs and EMS stated Resident #150 had a fall two hours prior. Staff had assisted Resident #150 back into bed and he had went back to sleep and staff had taken his vital signs that morning and Resident #150 was tachycardic (elevated heart rate) and hypoxic (low oxygen saturation).Telephone interview on 11/17/25 at 12:43 P.M. with Resident #150's Power of Attorney (POA) revealed she had received a call on 10/02/25 at approximately 3:45 A.M. that stated Resident #150 had fallen and was being sent to the emergency department. The POA further stated she had obtained a copy of the EMS report that stated a call was place on 10/01/25 before midnight. Interview on 11/17/25 at 3:36 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #431 confirmed fall investigation had included Resident #150 had a fall on 10/02/25 at approximately 3:00 A.M. Review of EMS run report confirmed a call was placed on 10/01/25 at 11:44 P.M. The DON and RRN #431 reported they were 365432 Page 9 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few unable to provide an explanation of the discrepancies in time frames for when Resident #150 fell and when EMS was summoned to the facility in response to Resident #150's fall. Review of the facility policy Fall Prevention and Management Policy dated 07/07/25 revealed falls will be reviewed by an interdisciplinary team. Such reviews should include results of fall risk assessment, discussion with resident and/or any witnessing parties as to potential causal factors, review of the environment where the fall occurred, and discussion as to any new interventions which may help to prevent future falls. This deficiency represents non-compliance investigated under Complaint Number 2656169. 365432 Page 10 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure adequate incontinence care was provided to Resident #28. This affected one resident (#28) of three residents reviewed for incontinence care. The facility census was 108. Findings include:Review of Resident #28's medical record revealed an admission date of 06/05/15. Diagnoses included stroke with left sided weakness, muscle weakness, and dementia. Review of Resident #28's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had no recorded cognition score due to resident was rarely/never understood. Resident #28 was incontinent of bowel and bladder and was dependent on staff for toileting. Review of the care plan updated 11/04/25 revealed Resident #28 was incontinent of bowel and bladder. Interventions included to assist with incontinence care as needed. Resident #28 was noted to be at risk for skin breakdown and had listed interventions to apply a skin barrier ointment after incontinence episodes. Review of Resident #28's current physician orders for November 2025 revealed an order to cleanse buttocks with soap and water and apply thick zinc barrier (barrier ointment used to form a protective barrier on the skin to shield the skin from irritants and moisture) every shift and as needed. Observation of incontinence care on 11/10/25 at 11:39 A.M. for Resident #28 with Certified Nursing Assistant (CNA) #385 revealed a large amount of dried stool to the crease of Resident #28's buttocks. Resident #28 was observed to have two bath blankets and a fitted sheet underneath him, which had large amounts of dried urine and other identifiable debris. There was an odor of urine coming from Resident #28's bed and bed linens. Interview with CNA #385 at time of observation revealed she had provided Resident #28 with incontinence care approximately one hour prior. CNA #385 reported Resident #28 had a reddened area to his buttocks and coccyx (tailbone) area at times and stated he required barrier cream to be applied after incontinence care. Observation of incontinence care at the time of interview revealed no evidence of barrier cream residue on Resident #28. CNA #385 confirmed the presence of the dried stool and confirmed she had not applied barrier cream to Resident #28 after she last provided incontinence care. CNA #385 confirmed she had not seen the soiled linens when she had previously provided incontinence care one hour prior. Review of facility policy titled Perineal Care Incontinence Care Procedure reviewed 10/30/25 revealed to turn patient on his/her side and wash the rectal area, working outward to include the buttocks. The policy additionally stated to apply a moisture barrier if care planned. This deficiency represents non-compliance investigated under Complaint Numbers 2656169, 2614362 and 2597119. 365432 Page 11 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health. This affected one resident (#150) and had the potential to affect all residents residing in the facility. The facility census was 108.Findings include: 1. Review of Resident #150's closed medical records revealed an admission date 09/04/19 with diagnoses including Parkinson's, dementia, muscle weakness and need for personal care assistance. Resident #150 was transferred to a local hospital on [DATE] and did not return to the facility. Review of the Medical Nutritional Therapy Observation dated 08/19/25 completed by Registered Dietitian (RD) #408 revealed that Resident #150's nutrition risk included dementia and potential for decreased awareness of hunger and thirst. RD #408 estimated Resident #150's fluid needs as 2040-2380 milliliters per day and that his current diet orders provided 1440 ml of fluid.Review of Resident #150 fluid intake revealed Resident #150 consumed 960 ml of fluids on 10/18/25 and 10/19/25 and consumed 650 ml of fluids on 10/20/25. Record review of Resident #150 hospital records dated 10/21/25 through 10/23/25 revealed resident was admitted to the hospital on [DATE] with sodium levels of 167 millimoles per liter (mmol/L). Resident was admitted for diagnosis that included change in mental status, acute urinary tract infection and acute hypernatremia (a condition of abnormally high sodium levels in the blood, often caused by dehydration from insufficient water intake, excessive sweating, vomiting, or diarrhea).Interview on 11/17/25 at 9:16 P.M. with the Director of Nursing (DON) and Regional Registered Nurse (RRN) #451 reviewed Resident #150's hospital laboratory results and the facility's fluid intake documentation. The DON and RRN #451 confirmed Resident #150 had decreased fluid intake on 10/18/25, 10/19/25, and 10/20/25 which could have contributed to the resident's dehydration identified at the hospital on [DATE]. 2. Observation on 11/10/25 at 4:53 P.M. revealed multiple residents were seated in the dining room. Two residents had small medication water cups but no styrofoam water cups. Continued observation at 5:01 P.M. revealed staff began to pass beverages for dinner that included milk, juice, and coffee. Interview on 11/10/25 at 5:11 P.M. with Certified Nursing Assistant (CNA) #380 revealed styrofoam cups were used to provide residents with water and were passed out to residents earlier in the day. CNA #380 guessed that styrofoam cups were probably in the resident ' s rooms.Observation on 11/17/25 at 11:44 A.M. of dining room C in the memory care unit revealed 14-15 residents were eating lunch, with only 2 residents with drinks. Continued observation at 11:46 A.M. of dining room A reveled Resident #84 and Resident #81 did not have anything to drink. Interview on 11/17/25 at 11:46 A.M. with CNA #397 confirmed Resident #84 and Resident #81 had no drinks provided to them. CNA #397 proceeded to provide the two residents with drinks after surveyor intervention. CNA #397 passed out drinks to dining room C residents at 11:51 A.M. She revealed lunch was passed out between 11:30 A.M. through 11:40 A.M. and she was not sure why residents were not provided with drinks. Observation and interviews on 11/17/25 at 11:54 A.M. revealed Resident #79 and Resident #92 had empty juice cups. Both residents reported they were still thirsty. Resident #92 said she had a water cup in the room but Resident #79 was unsure if he had a water cup.Interview on 11/17/25 at 11:56 A.M. with CNA #397 confirmed Resident #79 and Resident #92 had empty juice cups and were still thirsty. CNA #397 refilled resident ' s cups after surveyor intervention.Interview on 11/18/25 at 4:44 P.M. with the Administrator and Assistant Director of Nursing (ADON) #356 revealed the plastic cups served at meals are 8 ounce cups of water. The facility does water passes at 10:00 A.M., 2:00 P.M. and HS (hour of sleep, bed time) with styrofoam cups. The Administrator was unsure why water was not being passed out during meal times. ADON #356 stated staff should be documenting intakes based on how much water they have Residents Affected - Few 365432 Page 12 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consumed and not just how much water a resident is provided. Observation on 11/18/25 at 5:00 P.M. of the secured unit with the DON and ADON #356 revealed the dinner beverage cart was present on the unit stocked with juice, lemonade, coffee, and milk. Observation of approximately 20 residents in dining room A revealed only 2 residents had water provided to them. Continued observation in dining room C revealed approximately 8 residents observed, all who did not have water provided to them. Review of the Resident Council meeting dated 09/09/25 and 10/07/25 revealed both meetings had complaints about water not being passed out. Review of in-servicing completed on 09/10/25 and 10/02/25 with staff revealed all staff had been re-educated that all staff were responsible for providing water to residents.Review of facility's Hydration Policy dated 06/22/20 revealed residents will be offered/administered sufficient fluid intake to maintain hydration. A variety of fluids will be offered to residents, depending on preference and nutritional/diagnosis considerations.This deficiency represents non-compliance investigated under Complaint Numbers 2657376, 2656169, and 2597119. 365432 Page 13 of 14 365432 11/25/2025 Diplomat Healthcare 9001 W 130th St North Royalton, OH 44133

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure laboratory results were timely obtained and results timely reported to the provider to allow for timely treatment of a urinary tract infection (UTI). This affected one resident (#12) of three residents reviewed for UTIs. The facility census was 108. Findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, major depressive disorder, hyperlipidemia, anxiety, hypertension and malignant neoplasm of large intestine.Continued record review revealed on 09/02/25, Resident #12 was seen by the nurse practitioner for UTI symptoms and ordered Urinalysis with Culture and Sensitivity (UA C&S). UA C&S orders were not placed until 09/04/25. On 09/04/25 a urine sample was collected and the sample was sent to the lab for testing. The urinalysis showed the resident's urine was turbid in color and tested positive for nitrite, leukocytes, epithelial, white blood cells, and bacteria. The facility received the urine culture results on 09/07/25 that indicated the resident had Escherichia coli extended-spectrum beta-lactamase (ESBL, an enzyme produced by certain bacteria that makes them resistant to many common antibiotics) in the urine. Further record review revealed on 09/10/25, Assistant Director of Nursing (ADON) #356 reported final UA C&S result to the nurse practitioner and received an order for Nitrofurantoin monohyd (an antibiotic) capsule 100 milligram (mg) twice daily for 7 days. Review of Resident #12's Medical Administration Record (MAR) for September 2025 revealed the ordered Nitrofurantoin monohyd was started on 09/10/25. Resident #12 completed the medication on 09/17/25. Interview on 11/17/25 at 3:23 P.M. with the Director of Nursing (DON) revealed she would check to see what the delay in reporting the urine culture was. The DON further stated the nurses are expected to report any abnormal laboratory results as soon as possible to the physician or ordering provider.Interview on 11/17/25 at 3:26 P.M. with ADON #356 revealed she reported the results of the urine culture to the nurse practitioner on 09/10/25 when she noticed the lab result had not been reported to the nurse practitioner. She was unsure what the reason for the delay in reporting the result was. Review of the facility policy Resident Change in Condition dated 06/27/24 revealed the Physician/Provider and Resident/Family/Responsible Party will be notified when there has been a need to alter the resident's medical treatment, including a change in provider orders.This deficiency represents non-compliance investigated under Complaint Number 2657376 and 2614362. 365432 Page 14 of 14